Association of Home Based Primary Care Enrollment with Social Determinants of Health for Older Veterans

Abstract The Veterans Administration (VA) Home-based Primary Care (HBPC) program provides comprehensive primary care to older Veterans with multiple chronic conditions who may be at risk of adverse health outcomes due to their social determinants of health. Area Deprivation Index (ADI) can be used as a surrogate measure of a Veteran’s social needs. The objective of this study was to estimate the effect of neighborhood disadvantage, as measured by ADI, on HBPC enrollment for a sample of older Veterans. We estimated a linear multivariate model in which the exposure was ADI and the outcome was enrollment in HBPC. Controls included clinical and demographic characteristics. In a final sample of 12,005,453 observations (total Veteran months) on 353,485 individual Veterans, 18.4% lived in high-deprivation neighborhoods (ADI greater than or equal to 80). Mean monthly probability of new HBPC enrollment was 0.0061. Controlling for clinical characteristics, housing instability, and distance from the medical center, Veterans residing in high-deprivation neighborhoods were 1.4% to 14.8% less likely to enroll in HBPC, though the association was not statistically significant. The VA HBPC program provides beneficial comprehensive, primary care services to Veterans at risk of poor health outcomes. However, a Veteran’s social determinants of health could prevent enrollment. More research is needed to determine the relationship between Veterans’ social needs and HBPC enrollment.

significantly less likely to be in mostly Non-White schools (public and private schools, p<0.001). The 1940s and 1950s cohort were more likely to join mostly White private schools than the 1930s cohort (odds ratio: 1.70 for 1940s and 1.62 for 1950s separately, p<0.005). Our findings illustrate a novel application of sequence analysis with life history data, as well as new evidence on recial segregation in early-life education within the last century.

AREA DEPRIVATION SHARE: A NEW MEASURE OF SOCIAL NEED FACED BY HOSPITALS SERVING OLDER ADULTS
Kellia Hansmann, 1 Amy Kind, 2 and Ryan Powell, 2 , 1. University of Madison,Wisconsin,United States,2. Geriatrics Division,Madison,Wisconsin,United States Medicare's Hospital Readmissions Reduction Program (HRRP) places disproportionate penalties on hospitals serving populations with complex medical and social needs. Without measures to identify the social need intensity of populations cared for by these hospitals, the HRRP cannot account for these risk factors, leading to burdensome penalties that may inadvertently hinder the ability of such hospitals to care for vulnerable populations. The objective of this study is to characterize the social need intensity of US hospital acute care populations. Using the Area Deprivation Index (ADI), a validated measure that ranks neighborhood socioeconomic disadvantage based on income, employment, housing, and education factors, we determined an "Area Deprivation Share" (ADS) for hospitals with 25 or more discharges using 100% of national Medicare claims data from 2013-2014. Hospital ADS is the proportion of qualifying discharges residing in the most disadvantaged neighborhoods (ADI ≥ 80th percentile) out of all qualifying discharges during the study period. Of 4,603 hospitals, median ADS was 17% (Interquartile Range: 6% -34%). Hospitals in the highest quintile of ADS (39% to 100%), were more frequently located in small towns or isolated rural areas (52.6%, comparted to 24.2% in lower quintiles) and served a higher percentage of Black patients (19.0%, comparted to 9.7% in lower quintiles). ADS is a potential tool to inform future Medicare policy decisions. Additional research will inform how hospitals target care processes to meet the needs of older adults with complex social needs. Further study can also explore overlapping disadvantage domains of socioeconomic status, race, and rurality.

VA Portland Health Care System, Portland, Oregon, United States
The Veterans Administration (VA) Home-based Primary Care (HBPC) program provides comprehensive primary care to older Veterans with multiple chronic conditions who may be at risk of adverse health outcomes due to their social determinants of health. Area Deprivation Index (ADI) can be used as a surrogate measure of a Veteran's social needs. The objective of this study was to estimate the effect of neighborhood disadvantage, as measured by ADI, on HBPC enrollment for a sample of older Veterans. We estimated a linear multivariate model in which the exposure was ADI and the outcome was enrollment in HBPC. Controls included clinical and demographic characteristics. In a final sample of 12,005,453 observations (total Veteran months) on 353,485 individual Veterans, 18.4% lived in high-deprivation neighborhoods (ADI greater than or equal to 80). Mean monthly probability of new HBPC enrollment was 0.0061. Controlling for clinical characteristics, housing instability, and distance from the medical center, Veterans residing in high-deprivation neighborhoods were 1.4% to 14.8% less likely to enroll in HBPC, though the association was not statistically significant. The VA HBPC program provides beneficial comprehensive, primary care services to Veterans at risk of poor health outcomes. However, a Veteran's social determinants of health could prevent enrollment. More research is needed to determine the relationship between Veterans' social needs and HBPC enrollment. Gathering stakeholder feedback is essential to designing and implementing relevant and actionable research. Additionally, stakeholders, particularly those directly impacted by an intervention, bring unique insights and experiences. This paper presents the process and findings of a research endeavor to co-design a pragmatic clinical trial with a Stakeholder Advisory Panel (SAP) in an effort to understand facilitators and barriers to conducting the research and implementing study findings. The proposed trial compares the impact of frozen, drop-shipped meals versus daily home-delivered meals provided by Meals on Wheels (MOW) programs on the ability of individuals living with dementia to age in place. We recruited nine SAP members, who were compensated for their time. The SAP is composed of a) MOW clients with dementia, b) family members of MOW clients with dementia, c) paid or volunteer MOW drivers, and d) MOW staff. A research team member facilitated two 90-minute meetings with the SAP members via Zoom. The topics of the meetings included potential benefits and challenges with each mode of meal delivery, the importance of the primary outcome (time to nursing home placement), topics of interest to include in interviews with clients and caregivers, and how participants would explain the study to a friend. Audio of the Zoom meetings was transcribed, and meeting summaries were shared with the SAP. Benefits of forming and engaging a SAP, as well as key lessons learned from SAP members and how recommendations were reflected in changes to the study protocol will be discussed.

INTERGENERATIONAL EDUCATION AND LATE-LIFE COGNITIVE DECLINE AMONG LATINOS AND NON-HISPANIC WHITES
Erika Meza, 1 Yea-Hung Chen, 1 Isabel Allen, 1 Hector Gonzalez, 2 M Maria Glymour, 3 and Jacqueline Torres, 3 , 1. University of California,San Francisco,San Francisco,California,United States,2. University of California,San Diego,San Diego,California,United States,3. University California San Francisco,San Francisco,California,United States Latinos face a growing burden of Alzheimer's Disease and related dementia (ADRD). Although education has been established as a strong predictor of ADRD, evidence to date is primarily for non-Latino cohorts. Few studies have assessed the relationship between intergenerational education and one's cognitive decline. Using the US Health and Retirement Study (N=20,860) we evaluated the joint effect of parental and own educational attainment on immediate and delayed verbal memory scores (range 0-10) from 1998 to 2016. The exposure was a 4-category variable based on parents' (highest of mother's or father's) and participant's own high school attainment: first-generation (parents' education <12; own ≥12); multi-generation (both ≥12: REF); neither graduated high school (both <12) and parent(s) graduated high school but not respondent (parents ≥12; own <12). Linear mixed effects models with subject-specific random intercepts and random slopes were stratified by race/ethnicity and tested for a 3-way interaction term (exposure x Latino x time). Models controlled for age, sex, place of birth and retest effects. Baseline verbal memory scores did not differ for first-generation compared to multi-generation high school graduates. Verbal memory decline was faster for first-compared to multi-generation high school graduates among non-Hispanic whites (e.g., β=-0.04; 95% CI: -0.05, -0.03, delayed verbal recall); among Latinos, first and multi-generation high school graduates had similar rates of decline (e.g. β=0.00; 95% CI: -0.03, 0.04, delayed verbal recall; p<0.001 for three-way interaction). Our findings suggest social and economic policies that facilitate educational achievement, particularly for important population subgroups, may reduce ADRD risk.

TYPOLOGY OF TRAUMATIC EVENTS AND PHYSICAL FUNCTION
Gabriella Dong, and Mengting Li, Rutgers, The State University of New Jersey, New Brunswick, New Jersey, United States Individuals experience various traumatic events over the life course, but little is known about the patterns of lifetime exposure to traumatic events. This study aims to identify traumatic event typology and examine its relationship with physical function. Data were from the 2017-2019 PINE study (N= 3,125). Traumatic events were evaluated by earthquake, typhoon, tornado, residential fire, physical assault, robbery, sexual assault, divorce, bereavement, cancer, homeless, imprisonment, and falsely accused. Physical function was measured by activities of daily living (ADL), with lower scores